CROSSING
THE GLOBAL
QUALITY CHASM

Improving Health
Care Worldwide

Committee on Improving the Quality of Health Care Globally

Board on Global Health

Board on Health Care Services

Health and Medicine Division

A Consensus Study Report of

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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This activity was supported by contracts between the National Academy of Sciences and the Institute of Global Health Innovation at Imperial College London, Johnson & Johnson, Medtronic Foundation, National Institutes of Health, U.S. Agency for International Development, U.S. President’s Emergency Plan for AIDS Relief, and Wellcome Trust. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-47789-5
International Standard Book Number-10: 0-309-47789-1
Digital Object Identifier: https://doi.org/10.17226/25152
Library of Congress Control Number: 2018959710

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Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25152.

COMITTEE ON IMPROVING THE QUALITY OF HEALTH CARE GLOBALLY

DONALD M. BERWICK (Co-Chair), Institute for Healthcare Improvement, Boston, Massachusetts

SANIA NISHTAR (Co-Chair), Heartfile, Islamabad, Pakistan

ANN AERTS, Novartis Foundation, Brussels, Belgium

MOHAMMED K. ALI, Emory University, Atlanta, Georgia

PASCALE CARAYON, University of Wisconsin–Madison

MARGARET AMANUA CHINBUAH, PATH, Accra, Ghana

MARIO ROBERTO DAL POZ, Instituto de Medicina Social, UERJ, Human Resources for Health, Rio de Janeiro, Brazil

ASHISH JHA, Harvard Global Health Institute, Harvard T.H. Chan School of Public Health, Harvard Medical School, Boston, Massachusetts

SHEILA LEATHERMAN, Gillings School of Global Public Health, University of North Carolina at Chapel Hill

TIANJING LI, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland

VINCENT OKUNGU, PharmAccess, Nairobi, Kenya

NEERAJ SOOD, Sol Price School of Public Policy, University of Southern California, Los Angeles, California

JEANETTE VEGA, Chilean National Health Fund, Santiago, Chile

MARCEL YOTEBIENG, College of Public Health, Ohio State University, Columbus, Ohio; and University of Kinshasa, Democratic Republic of Congo

Study Staff

MEGAN SNAIR, Study Director (through July 2018)

EESHAN KHANDEKAR, Research Associate

SARAH ANNE NEW, Senior Program Assistant

JULIE PAVLIN, Director, Board on Global Health, and Study Director (from August 2018)

SHARYL NASS, Director, Board on Health Care Services

Consultants

RONA BRIERE, Arlington, Virginia

JENNIE KWON, National Academy of Medicine Fellow, St. Louis, Missouri

IRENE PAPANICOLAS, Department of Health Policy, London School of Economics, London, United Kingdom; Harvard Global Health Institute, Boston, Massachusetts

LIANA WOSKIE, Harvard Global Health Institute, Boston, Massachusetts

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ENRIQUETA C. BOND, Burroughs Wellcome Fund Partner, and BRADFORD H. GRAY, Urban Institute. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Preface

This report minces no words about the magnitude and costs of the “global quality chasm.” Although evidence is scattered and incomplete, the conclusion is inescapable: For billions of people, universal health coverage—the important mainstay of the World Health Organization’s (WHO’s) Sustainable Development Goal (SDG) 3—will be an empty vessel unless and until quality improvement, for all nations, becomes as central an agenda as universal health coverage itself. In view of the immense dedication and effort of tens of millions of health care workers worldwide, often against massive obstacles of resource limitations, political and social fragmentation, corruption, collusion, and even threats to personal security, the central assertion that the current system too often fails to provide high-quality care is not to be made lightly or with disrespect. The study committee vehemently rejects the idea that the workforce is generally at fault, neglectful, or uncaring. On the contrary, without doubt, they deserve credit and the world’s gratitude for a large proportion of the extraordinary progress in population health of the Millennium Development Goal (MDG) and early SDG eras.

What we do believe, informed by the guiding intellectual framework of this report—“systems thinking”—is that many of these workers, the would-be healers of the world, are ill served by being embedded in and dependent on systems of care that impede excellence rather than supporting it, and that drain their energy rather than nurturing it. Systemic conditions—such as fragmentation, malaligned payment, unclear goals, poor training, unreliable supply chains, burdensome rules, inadequate information flows, lack of

useful data, corruption, and fear—prevent even the most willing workforce from carrying out its daily tasks successfully and contributing to the success of the whole system. As a result, patients suffer needlessly; communities squander scarce resources; and the workforce itself becomes frustrated and exhausted as a part of the ill-functioning system.

The good news in this report is that all these problems are remediable—indeed, preventable. Foundational, of course, are adequate social investments in health care supplies, personnel, equipment, and space; these are preconditions for excellence. But alone, they do not assure excellence. To mobilize change, system leaders must reassess values, principles, and systems designs. Even in wealthy settings, where resources are abundant, quality can and does fail because of improper care designs and poor systemic conditions, such as those listed above. Keys to success, given adequate resources, lie in modern, evidence-based methods of quality assurance and improvement. They also lie in full-hearted embrace of the new digital age of medical care, and in making sure that the well-being of patients and the integrity of their care journeys are the compass bearings for all that we do. It is leaders, above all, who have the opportunity and responsibility to nurture those methods and to continually reinforce those aims.

The committee is convinced, after 1 year of study and reflection, that these values—especially person-centered care—and these systems-based methods hold as much promise in low- and middle-income settings as in wealthy ones. This report sets out an agenda for action on policy, management, and clinical care that, we believe, can deliver far better outcomes for the people who depend on us and far more satisfying and respectful conditions of work for those who try to help.

This report joins two others from important organizations: one from a consortium of WHO, the World Bank, and the Organisation for Economic Co-operation and Development, and another from The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era. Together, this report and these two sibling efforts offer the entire global health community evidence-based guidance and, we hope, further motivation to engage in comprehensive health care redesign in pursuit of continual quality improvement as a priority equal to what is now, happily, assigned to universal health coverage. The combination can save lives, financial resources, and pride and joy in the workforce, all at the same time.

If 2018 has been a year of study and reports on quality, let 2019 and beyond be an era of action on quality.

Donald M. Berwick, Co-Chair
Sania Nishtar, Co-Chair
Committee on Improving the Quality of Health Care Globally

Acknowledgments

This Consensus Study Report would not have been possible without the invaluable contributions from many experts and stakeholders dedicated to global health. The committee would like to thank all of the speakers (whose full names and affiliations are found in Appendix A) and participants who played a role in the public workshops conducted for this study, as well as the many others who provided valued insight and responded to rapid requests for information to accommodate our short and demanding timeline. Many of these contributors are listed below:

The committee would also like to thank the sponsors of this study for their generous financial support: Johnson & Johnson, National Institutes of Health, U.S. Agency for International Development, and U.S. President’s Emergency Plan for AIDS with additional support from the Institute of Global Health Innovation at Imperial College London, Medtronic Foundation, and Wellcome Trust. A special thanks and acknowledgment go to the Institute of Global Health Innovation and the National Institute for Health Research Imperial Patient Safety Translational Research Centre for its time and intellectual contribution in planning the committee’s March meeting on the future of health care. We also thank Peter Buckle and colleagues for their white paper testimony on the role of human factors and Alain Labrique for his paper on technology and the future of health care; special thanks also goes to the Harvard Global Health Institute’s Initiative on Global Health Quality for the analysis estimating the burden of poor quality health care and its economic consequences.

Finally, deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process: Lauren Shern and Maryjo Oster on the Report Review Committee; Greta Gorman and Tina Ritter in the Communications office; Rebecca Morgan and Jorge Torres-Mendoza at the Research Center for their assistance in fact checking the report; and Victor Dzau for his assistance in and support of the project.

Contents

ACRONYMS AND ABBREVIATIONS

SUMMARY

1 INTRODUCTION

The Sustainable Development Goals and the Universal Health Coverage Agenda

Challenges for Health Care Quality

A Poor Patient Journey

Charge, Approach, and Scope of This Study

Organization of the Report

References

PART I: THE IDEAL VISION FOR FUTURE HEALTH CARE

2 THE PATH TO A HIGH-QUALITY FUTURE: THE NEED FOR A SYSTEMS APPROACH AND A PERSON-CENTERED SYSTEM

The Need to Redouble Efforts for a Systems Approach

Redesign for a Person-Centered Health System

Summary and Recommendation

References

3 OPTIMIZING THE PATIENT JOURNEY BY LEVERAGING ADVANCES IN HEALTH CARE

Global Trends in Health Care

Implications for Quality: Person-Centeredness, Accessibility, and Equity

Moving from Reactive to Predictive Care

Needed Organizational and Care Delivery Changes

Cautions for Quality in the Future System

Summary and Recommendations

References

PART II: THE CURRENT STATE OF QUALITY IN HEALTH CARE

4 THE CURRENT STATE OF GLOBAL HEALTH CARE QUALITY

The State of Quality Across Domains

The Burden of Low-Quality Care

Data Sources and Limitations

Variability in Quality: Where Are the Gaps?

Tracking Progress in Quality: Where Are the Metrics?

Summary and Recommendation

References

5 HIGH-QUALITY CARE FOR EVERYONE: MAKING INFORMAL CARE VISIBLE AND ADDRESSING CARE UNDER EXTREME ADVERSITY

Informal Health Care Providers: Overview

Health Care Quality in Settings of Extreme Adversity

Summary and Recommendations

References

6 THE CRITICAL HEALTH IMPACTS OF CORRUPTION

The Impact of Corruption on the Health of Populations

Types of Corruption in Health Care

Challenges to Effective Universal Health Coverage Posed by Corruption

Strategies for Reducing Corruption in Health Care

Summary and Recommendation

References

PART III: THE PATH TO CONTINUAL GLOBAL IMPROVEMENT

7 EMBEDDING QUALITY WITHIN UNIVERSAL HEALTH COVERAGE

The Necessary Link Between Universal Health Coverage and Quality

Universal Health Coverage as an Opportunity for Quality Improvement

The Need for Government Commitment to Quality Within Universal Health Coverage

Summary and Recommendations

References

8 ESTABLISHING A CULTURE OF CONTINUAL LEARNING

What Is a Learning Health Care System?

The Components of a Learning Health Care System

A Research and Development Agenda

Summary and Recommendations

References

APPENDIXES

A PUBLIC MEETING AGENDAS

B METHODS FOR RAPID REVIEW

C COMMITTEE MEMBER BIOSKETCHES

D METHODS FOR CHAPTER 4

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Boxes, Figures, and Tables

BOXES

1-1 Definition of Health Care Quality

1-2 Statement of Task

2-1 Case Study: Misalignment of Incentives Across Organizational Levels

2-2 The Committee’s Design Principles in Action

3-1 Case Study: China’s WeChat

3-2 Case Study of Optimizing Community Health Workers

3-3 Optimizing Community Health Systems

4-1 Safety Case Study: Substandard and Falsified Medications

4-2 Effectiveness Case Study: Hypertension

4-3 Timeliness Case Study: Time to Antenatal/Postnatal Care

4-4 Efficiency Case Study: Overuse in Antibiotic Prescribing

4-5 Equity Case Study: Cervical Cancer

4-6 Equity Case Study: Breast Cancer

5-1 Case Study: Palestinian Refugees in the West Bank

6-1 Corruption Is Widespread

6-2 Equipment Graveyards

7-1 Case Study: Patient Detention

7-2 Examples of Nationwide Accreditation Programs Designed to Improve Quality

7-3 Pay-for-Performance Schemes

7-4 Case Study: Rwanda’s Community-Based Health Insurance Program (CBHI)

8-1 Case Studies of a Learning Health Care System

FIGURES

S-1 Overall number of deaths from poor-quality care annually in low- and middle-income countries compared with total deaths, in thousands

S-2 Guiding framework for the transformation of care delivery

1-1 The patient journey from a life-course perspective

1-2 Health system levels that can impact one another bidirectionally

2-1 Integration of conceptual frameworks guiding health systems and quality of care

2-2 Guiding framework for the transformation of care delivery

3-1 Future expectations for the quality of health care globally

3-2 Trends in health care technology throughout the decades

3-3 Percentage of respondents willing or unwilling to use an “intelligent health care assistant” via phone or computer

3-4 Primary care acting as a hub of coordination to provide person-centered care

3-5 Principles for digital development

3-6 The PATH-Vital Wave data use cycle

4-1 Stages of health care service coverage

4-2 National levels of dissatisfaction with care

4-3 Variation in mortality rates for ineffective care, low- and middle-income versus high-income countries

4-4 Total overall deaths and quality-related deaths by condition

4-5 Availability of published literature in low- and middle-income countries (LMICs) on five safety indicators (2007–2017)

5-1 Interventions to improve health services in the informal sector

5-2 Proportion of populations in extreme poverty living in fragile contexts, 2016 and 2030

5-3 Poor overall patient experience in fragile states compared with all low- and middle-income countries (LMICs)

5-4 Experience of disrespect in fragile states compared with all low- and middle-income countries (LMICs)

6-1 Chain of malpractice in publicly owned health care facilities

6-2 Publications on different types of corruption, 2000 to 2018

6-3 The public–private nexus in institutionalizing corruption

7-1 A conceptual model for mixed health system stewardship

7-2 Framework for improvement in health care quality

7-3 The eight elements of a National Quality Policy and Strategy

8-1 The learning health care system cycle

B-1 Article exclusion flow chart

TABLES

2-1 Proposed New Design Principles to Guide Health Care

3-1 Comparison of Bottom-Up and Top-Down Approaches to the Development of Digital Health Systems

4-1 Safety Events Occurring in Low- and Middle-Income Countries (LMICs)

4-2 Conditions Represented in the Effectiveness Domain

4-3 Definition of Ineffectiveness Indicators

4-4 Number of People Impacted by Ineffective Treatment for Communicable Diseases in Low- and Middle-Income Countries, Annually (millions)

4-5 Deaths and Disability Resulting from Ineffective Care for Communicable Diseases in Low- and Middle-Income Countries, Annually (millions)

4-6 Number of People Impacted by Ineffective Treatment for Noncommunicable Diseases in Low- and Middle-Income Countries, Annually (millions)

4-7 Deaths and Disability Resulting from Ineffective Care for Noncommunicable Diseases in Low- and Middle-Income Countries, Annually (millions)

4-8 Quality-Related Deaths Resulting from Ineffective Care for Maternal and Child Health in Low- and Middle-Income Countries, Annually

4-9 Patient-Reported Data on Satisfaction with Wait Time by Country, Published Literature

4-10 Deaths and Years of Life Lost to Vaccine-Preventable Conditions (Low- and Middle-Income Countries [LMICs])

4-11 Number of Studies by Country for Selected Safety Indicators

4-12 Primary Data Sources and Number of Low- and Middle-Income Countries Represented for Selected Conditions

Annex Table 4-1 Excess Costs Resulting from Safety Events Occurring in Low- and Middle-Income Countries Annually, Low Estimates (1 × gross national income per capita in millions)

Annex Table 4-2 Excess Costs Resulting from Ineffective Care for Communicable Diseases in Low- and Middle-Income Countries Annually, Low Estimates (1 × gross national income per capita in millions)

Annex Table 4-3 Excess Costs of Deaths and Disability Resulting from Ineffective Care for Noncommunicable Diseases in Low- and Middle-Income Countries Annually (millions)

5-1 Quality-Related Deaths in Fragile States and Low- and Middle-Income Countries (LMICs) Annually, 185

8-1 Components of a Learning Health Care System

B-1 Search Strategy

Acronyms and Abbreviations